In 2010, The Kids Asthma Management Program (KAMP) of the Crozer-Keystone Health System partnered with a local environmental justice community organization, the Chester Environmental Partnership (CEP) to implement an indoor/outdoor environmental remediation and education program using peer counselors and a masters-level certified health education specialist as program manager to respond to the growing prevalence of asthma in the city. This home-based program for Chester City families with asthmatic children between the ages of 2 - 17 years taught families how to reduce or remove common household asthma triggers, reviewed the proper use of asthma medications and empowered families to work in partnership with their health care providers on an Asthma Action Plan (AAP). Families received an "asthma-friendly home kit" that included such items as allergen-proof bedding and non-toxic cleaning and pest control supplies. Families learned how to keep their home and surrounding areas trigger free. CEP conducted neighborhood block clean-ups to help reduce triggers such as rodents. Swarthmore College conducted a data analysis which found that CHAPP made it possible for participating families to reduce emergency room visits and school absenteeism, as well as use of rescue medications for their children.
The program included a four-to-six-week intervention in which peer counselors use standard lesson plans based on the EPA Asthma Home Environment Checklist, other EPA literature and components of Georgetown University's You Can Control Asthma curriculum. Prior to the intervention, the program manager and a peer counselor co-facilitate a client intake visit. During the client intake visit, baseline data is collected including the validated Asthma Control Test (ACT).
Following the 4-visit education program with the peer counselor, the program manager engages in a 6-month follow-up period that entails a 2-week follow up phone survey, a 3-month follow-up phone survey, and a final 6-month follow-up home visit during which families complete a final survey and other data collection tools. The part-time peer counselors outreached to 382 families and were able to enroll 132 children.
Eighteen percent (18%) of the parents in the evaluation sample had less than high school education and 44% were high school graduates. The average number of asthmatic children per family was 2.61, with some families having as many as six asthmatic children. Of the children 54% were male. The average age of the children at time of diagnosis was nearly 2 years. A significant number of families were low income; 11% had annual incomes less than $10,000 and 24% had incomes between $10,000 - $19,000. Most of the families were renters, with 77% living in row or twin houses and 23% lived in apartments. For household exposure to tobacco smoke, a major asthma trigger, 44% had smokers in the home.
Participants saw enhanced conditions when it came to severity and control of asthma. For both children above and below the age of 12, there was a significant improvement in pre-and posttest asthma control scores (ACT for ages 4-11 years old (P=.076, ACT for 12 years and older P=.063), in addition to a decrease in visits to the emergency room (P=.006). The resulting change in asthma control score was on average a 2.3 point increase out of 25 points for children 12 and over.
The improvement was especially great for children whose asthma was initially considered "severe" based on the standard for asthma control score. For the children who began with an ACT score of less than 20, there was significant improvement from pretest to posttest (ACT ages 4-11, P=.001, ACT ages 12 and older P=.050) and a mean difference of 3 and 4 points, respectively. This substantial improvement for these children suggests that the intervention program, though helpful to all children, was especially beneficial for children who initially had less control over their asthma.
The binomial test, comparing the percentage of children who initially had an Asthma Action Plan (AAP) and those who had it by the end was statistically significant (P<.001). By the end of the program, there was a 38% increase in the number of children with an AAP. There was also a significant increase in the percentage of kids who shared the AAP with their school nurse (P<.001). Clearly, the program was effective in facilitating the proper completion and use of the AAP.
There was also a statistically significant reduction in the number of trips to the ER (P=0.006). On average, a child missed approximately 5 more days of school before the intervention than after. As the number of a child's medications increased, both the number of school absences and the number of overnight stays in the hospital decreased (P=.03, P=.048). These differences corroborate the matched pair's analysis of the ACT and hospital visits. The improvement was greater for children with a greater number of medications, which might be considered an indicator of severity of asthma. This provides further evidence that the program was effective for children with more severe asthma.
CHAPP combined a strong community centered partnership with a home and neighborhood-based intervention that may prove to be a cost-effective way to reduce the health and financial burden of asthma on inner-city, disadvantaged, environmentally challenged populations.